california’s medi-cal 2020 demonstration (11-w …...in dy14-q2, dhcs hosted a sac meeting on...

CALIFORNIA’S MEDI-CAL 2020

DEMONSTRATION (11-W-00103/9)

Section 1115(a) Waiver Quarterly Report

Demonstration/Quarter Reporting Periods: Demonstration Year: Fourteen (07/01/2018 – 06/30/2019)

Second Quarter Reporting Period: 10/01/2018 – 12/31/2018

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Table of Contents

Introduction ..................................................................................................................... 3

Waiver Deliverables: ....................................................................................................... 6

STCs Item 18: Post Award Forum ............................................................................... 6

STCs Item 26: Monthly Calls ....................................................................................... 6

STCs Item 201: Budget Neutrality Monitoring Tool...................................................... 7

Access Assessment ........................................................................................................ 8

California Children’s Services (CCS)............................................................................... 9

Community-Based Adult Services (CBAS).................................................................... 11

Dental Transformation Initiative (DTI)............................................................................ 25

Drug Medi-Cal Organized Delivery System (DMC-ODS) .............................................. 35

Financial/Budget Neutrality Progress: DSHP/LIHP ....................................................... 42

Global Payment Program (GPP) ................................................................................... 43

Public Hospital Redesign and Incentives in Medi-Cal (PRIME)..................................... 45

Seniors and Persons with Disabilities (SPD)................................................................. 51

Whole Person Care Pilot (WPC) ................................................................................... 55

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INTRODUCTION

On March 27, 2015, the Department of Health Care Services (DHCS) submitted an application to renew the State’s Section 1115 Waiver Demonstration to the Center for Medicare & Medicaid Services (CMS) after many months of discussion and input from a wide range of stakeholders and the public to develop strategies for how the Medi-Cal program will continue to evolve and mature over the next five years. A renewal of this waiver is a fundamental component to California’s ability to continue to successfully implement the Affordable Care Act beyond the primary step of coverage expansion. On April 10, 2015, CMS completed a preliminary review of the application and determined that the California’s extension request has met the requirements for a complete extension request as specified under section 42 CFR 431.412(c).

On October 31, 2015, DHCS and CMS announced a conceptual agreement that outlines the major components of the waiver renewal, along with a temporary extension period until December 31, 2015 of the past 1115 waiver to finalize the Special Terms and Conditions. The conceptual agreement included the following core elements:

Global Payment Program for services to the uninsured in designated public hospital (DPH) systems

Delivery system transformation and alignment incentive program for DPHs and district/municipal hospitals, known as PRIME

Dental Transformation Incentive program Whole Person Care pilot program that would be a county-based, voluntary

program to target providing more integrated care for high-risk, vulnerable populations

Independent assessment of access to care and network adequacy for Medi-Cal managed care members

Independent studies of uncompensated care and hospital financing The continuation of programs currently authorized in the Bridge to Reform

waiver, including the Drug Medi-Cal Organized Delivery System (DMC-ODS), Coordinated Care Initiative, and Community-Based Adult Services (CBAS)

Effective December 30, 2015, CMS approved the extension of California’s section 1115(a) Demonstration (11-W-00193/9), entitled “California Medi-Cal 2020 Demonstration.” Approval of the extension is under the authority of the section 1115(a) of the Social Security Act, until December 31, 2020. The extension allows the state to extend its safety net care pool for five years, in order to support the state’s efforts towards the adoption of robust alternative payment methodologies and support better integration of care.

The periods for each Demonstration Year (DY) of the Waiver will be as follows:

DY 11: January 1, 2016 through June 30, 2016 DY 12: July 1, 2016 through June 30, 2017 DY 13: July 1, 2017 through June 30, 2018 DY 14: July 1, 2018 through June 30, 2019

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DY 15: July 1, 2019 through June 30, 2020 DY 16: July 1, 2020 through December 31, 2020

To build upon the state’s previous Delivery System Reform Incentive Payment (DSRIP) program, the new redesigned pool, the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program aims to improve the quality and value of care provided by California’s safety net hospitals and hospital systems. The activities supported by the PRIME program are designed to accelerate efforts by participating PRIME entities to change care delivery by maximizing health care value and strengthening their ability to successfully perform under risk-based alternative payment models (APMs) in the long term, consistent with CMS and Medi-Cal 2020 goals. Using evidence-based, quality improvement methods, the initial work will require the establishment of performance baselines followed by target setting and the implementation and ongoing evaluation of quality improvement interventions. PRIME has three core domains:

Domain 1: Outpatient Delivery System Transformation and Prevention Domain 2: Targeted High-Risk or High-Cost Populations Domain 3: Resource Utilization Efficiency

The Global Payment Program (GPP) streamlines funding sources for care for

California’s remaining uninsured population and creates a value-based mechanism. The GPP establishes a statewide pool of funding for the remaining uninsured by combining

federal DSH and uncompensated care funding, where county DPH systems can

achieve their “global budget” by meeting a service threshold that incentivizes movement

from high-cost, avoidable services to providing higher-value, preventive services.

To improve the oral health of children in California, the Dental Transformation Initiative (DTI) will implement dental pilot projects that will focus on high-value care, improved access, and utilization of performance measures to drive delivery system reform. This strategy more specifically aims to increase the use of preventive dental services for children, to prevent and treat more early childhood caries, and to increase continuity of care for children. The DTI covers four domains:

Domain 1: Increase Preventive Services Utilization for Children Domain 2: Caries Risk Assessment and Disease Management Domain 3: Increase Continuity of Care Domain 4: Local Dental Pilot Programs

Additionally, the Whole Person Care (WPC) pilot program will provide participating entities with new options for providing coordinated care for vulnerable, high-utilizing Medicaid recipients. The overarching goal of the WPC pilots is to better coordinate health, behavioral health, and social services, as applicable, in a patient-centered manner with the goals of improved beneficiary health and wellbeing through more efficient and effective use of resources. WPC will help communities address social

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determinants of health and will offer vulnerable beneficiaries with innovative and potentially highly effective services on a pilot basis.

Assembly Bill (AB) 1568 (Bonta and Atkins, Chapter 42, Statutes of 2016) established the “Medi-Cal 2020 Demonstration Project Act” that authorizes DHCS to implement the objectives and programs, such as WPC and DTI, of the Waiver Demonstration, consistent with the Special Terms and Conditions (STCs) approved by CMS. The bill also covered having the authority to conduct or arrange any studies, reports, assessments, evaluations, or other demonstration activities as required by the STCs. The bill was chaptered on July 1, 2016, and it became effective immediately as an urgency statute in order to make changes to the State’s health care programs at the earliest possible time.

Operation of AB 1568 is contingent upon the enactment of Senate Bill (SB) 815 (Hernandez and de Leon, Chapter 42, Statutes of 2016). SB 815, chaptered on July 8, 2016, establishes and implements the provisions of the state’s Waiver Demonstration as required by the STCs from CMS. The bill also provides clarification for changes to the current Disproportionate Share Hospital (DSH) methodology and its recipients for facilitating the GPP program.

On June 23, 2016, DHCS submitted a waiver amendment request to CMS to expand the definition of the lead entity for WPC pilots to include federally recognized Tribes and Tribal Heath Programs. On August 29, 2016, DHCS proposed a request to amend the STCs to modify the methodology for determining baseline metrics for incentive payments and provide payments for a revised threshold of annual increases in children preventive services under the DTI program. On December 8, 2016, DHCS received approval from CMS for the DTI and WPC amendments.

On November 10, 2016, DHCS submitted a waiver amendment proposal to CMS regarding the addition of the Health Homes Program (HHP) to the Medi-Cal managed care delivery system. Under the waiver amendment, DHCS would waive Freedom of Choice to provide HHP services to members enrolled in the Medi-Cal managed care delivery system. Fee-for-service (FFS) members who meet HHP eligibility criteria may choose to enroll in a Medi-Cal managed care plan to receive HHP services, in addition to all other state plan services. HHP services will not be provided through the FFS delivery system. DHCS received CMS’ approval for this waiver amendment on December 9, 2017.

On February 16, 2017, DHCS submitted a waiver amendment proposal to CMS for the addition of the Medi-Cal Access Program (MCAP) population to the Medi-Cal managed care delivery system, with a requested effective date of July 1, 2017. MCAP provides comprehensive coverage to pregnant women with incomes above 213 up to and including 322 percent of the federal poverty level. The MCAP transition will mirror the benefits of Medi-Cal full-scope pregnancy coverage, which includes dental services coverage.

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During a conference call on April 26, 2017, CMS advised the state to convert DHCS’ amendment proposal into a Children Health Insurance Program (CHIP) SPA in its place. In response to CMS’ guidance, DHCS sent CMS an official letter of withdrawal for the MCAP amendment request on May 24, 2017.

On May 19, 2017, DHCS submitted a waiver amendment proposal to CMS to continue coverage for California’s former foster care youth up to age 26, whom were in foster care under the responsibility of a different state’s Medicaid program at the time they turned 18 or when they “aged out” of foster care. DHCS received CMS’ approval for the former foster care youth amendment on August 18, 2017.

On June 1, 2017, DHCS also received approval from CMS for the state’s request to amend the STCs in order to allow a city to serve in the lead role for the WPC pilot programs.

WAIVER DELIVERABLES:

STCs Item 18: Post Award Forum

The purpose of the Stakeholder Advisory Committee (SAC) is to provide DHCS with valuable input from the stakeholder community on ongoing implementation efforts for the State’s Section 1115 Waiver, as well as other relevant health care policy issues impacting DHCS. SAC members are recognized stakeholders/experts in their fields, including, but not limited to, beneficiary advocacy organizations and representatives of various Medi-Cal provider groups. SAC meetings are conducted in accordance with the Bagley-Keene Open Meeting Act, and public comment occurs at the end of each meeting.

In DY14-Q2, DHCS hosted a SAC meeting on October 25, 2018 to provide waiver implementation updates and address stakeholder questions and comments. DHCS reviewed the timing for potential 1115 waiver renewal discussions and stakeholder engagements, in addition to the waiver elements being considered.

The meeting agenda is available on the DHCS website: https://www.dhcs.ca.gov/services/Documents/Oct25SACAgenda.pdf. The meeting minutes are also available online: https://www.dhcs.ca.gov/services/Documents/SAC_102518_MeetingSummary.pdf

STCs Item 26: Monthly Calls

This quarter, CMS and DHCS conducted waiver monitoring conference calls on October 10, 2018, and December 10, 2018, to discuss any significant actual or anticipated developments affecting the Medi-Cal 2020 Demonstration. The following topics were discussed: Rady Children’s Hospital CCS Pilot, WPC Program Updates, HHP Updates, DY 13 Annual Report, DMC-ODS Grievances and Appeals, and Financial Reporting Activities.

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https://www.dhcs.ca.gov/services/Documents/Oct25SACAgenda.pdfhttps://www.dhcs.ca.gov/services/Documents/SAC_102518_MeetingSummary.pdf

STCs Item 201: Budget Neutrality Monitoring Tool

The State and CMS are still jointly developing a budget neutrality monitoring tool for the State to use for quarterly budget neutrality status updates and for other situations when an analysis of budget neutrality is required.

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ACCESS ASSESSMENT

California’s Section 1115(a) Medicaid Waiver Demonstration STCs require DHCS to contract with its External Quality Review Organization (EQRO), Health Services Advisory Group, to conduct a one-time access assessment to care.

The EQRO provided DHCS with the Access Assessment data requirements and

submitted their data request to DHCS on October 29, 2018. DHCS and the EQRO

began bi-monthly meetings on November 7, 2018, to ensure the Access Assessment

project continues to move forward. On December 14, 2018, DHCS submitted

administrative and survey-based data to the EQRO to begin preliminary analytic review

and quality assurance checks.

DHCS and the EQRO will complete the following activities as part of the Access

Assessment project:

Initial draft report meeting with Advisory Committee for review and comment; Initial draft report posted for 30-day public comment period; Exit Advisory Committee Meeting; and Final report submission to CMS ten months following CMS’ approval of the

Assessment Design and publishing to the DHCS’ website.

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CALIFORNIA CHILDREN SERVICES (CCS)

The CCS Program provides diagnostic and treatment services, medical case

management, and physical and occupational therapy services to children under age 21

with CCS-eligible medical conditions. Examples of CCS-eligible conditions include, but

are not limited to, chronic medical conditions such as cystic fibrosis, hemophilia,

cerebral palsy, heart disease, cancer, and traumatic injuries.

The CCS Program is administered as a partnership between local CCS county

programs and DHCS. Approximately 75 percent of CCS-eligible children are Medi-Cal

eligible.

The pilot project under the 1115 Waiver is focused on improving care provided to

children in the CCS Program through better and more efficient care coordination, with

the goals of improved health outcomes, increased consumer satisfaction, and greater

cost effectiveness, by integrating care for the whole child under one accountable entity.

The positive results of the project could lead to improvement of care for all 186,000

children enrolled in CCS.

DHCS is piloting two (2) health care delivery models of care for children enrolled in the

CCS Program. The two demonstration models include provisions to ensure adequate

protections for the population served, including a sufficient network of appropriate

providers and timely access to out-of-network care when necessary. The pilot projects

will be evaluated to measure the effectiveness of focusing on the whole child, not just

the CCS condition. The pilots will also help inform best practices, through a

comprehensive evaluation component, so that at the end of the demonstration period

decisions can be made on permanent restructuring of the CCS Program design and

delivery systems.

The two (2) health care delivery models include:

Provider-based Accountable Care Organization (ACO)

Medi-Cal Managed Care Plan (existing)

In addition to Health Plan of San Mateo (HPSM), DHCS contracted with Rady Children’s Hospital of San Diego (RCHSD), an ACO beginning July 1, 2018.

Enrollment Information:

The monthly enrollment for Health Plan San Mateo (HPSM) CCS Demonstration Project (DP) is reflected in the table below. HPSM is reimbursed based on a capitated per-member-per-month payment methodology using the CAPMAN system.

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Month RCHSD

Enrollment Capitation

Rate Capitation Payment

18-July 0 $2,733.54 $0.00

18-Aug 44 $2,733.54 $120,275.76

18-Sep 128 $2,733.54 $349,893.12

18-Oct 151 $2,733.54 $412,764.54

18-Nov 210 $2,733.54 $574,043.40

18-Dec 321 $2,733.54 $877,466.34

Total $2,334,443.16

RCHSD Monthly Enrollment

Demonstration Programs

Month 1 Month 2 Month 3 Quarter Total Quarter

Enrollees

CCS 151 210 321 2 682

Outreach/Innovative Activities:

Nothing to report.

Operational/Policy Developments/Issues:

CCS Pilot Protocols

California’s 1115 Waiver Renewal, Medi-Cal 2020 Waiver, was approved by Federal CMS on December 30, 2015. The Waiver contains STCs for the CCS Demonstration. STC 54 required DHCS to submit to CMS an updated CCS Pilot Protocols (Protocols) to include proposed updated goals and objectives and the addition of required performance measures by September 30, 2016. DHCS is awaiting approval for the CCS protocols, however DHCS received the formal approval package from CMS on November 17, 2017, for the CCS evaluation design.

Health Plan of San Mateo Demonstration Project

HPSM’s contract for the CCS Demonstration Project ceased effective June 30, 2018. All CCS Demonstration members in HPSM were transitioned into HPSM’s managed care plan effective July 1, 2018.

Rady Children’s Hospital of San Diego Demonstration Project

RCHSD – San Diego pilot demonstration was implemented on July 1, 2018. RCHSD was brought up as a full-risk Medi-Cal managed care health plan that services CCS beneficiaries in San Diego County that have been diagnosed with one of five eligible medical conditions. Members are currently being enrolled into RCHSD.

Demonstration Schedule

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The RCHSD CCS Demonstration Pilot implemented July 1, 2018.

Consumer Issues:

CCS Quarter Grievance Report

In August 2018, members began enrolling in RCHSD. RCHSD notified DHCS that there were no member grievances to report for DY14-Q2.

Financial/Budget Neutrality Development/Issues:

Nothing to report.

Quality Assurance/Monitoring Activities:

Nothing to report.

Evaluation:

DHCS submitted a revised evaluation design to CMS on May 15, 2017. DHCS received CMS’ draft evaluation comments on June 19, 2017, and DHCS responded to CMS on July 14, 2017. DHCS received further CMS comments on September 12, 2017, and DHCS responded to CMS on October 10, 2017. DHCS received preliminary approval of the evaluation design from CMS on November 3, 2017, and the formal approval package for the CCS evaluation design on November 17, 2017. The approval documents as well as the final design are available on this website: http://www.dhcs.ca.gov/provgovpart/Pages/Medi-Cal2020Evaluations.aspx.

DHCS sought out applications for the evaluator on October 9, 2018. After reviewing the proposals, DHCS selected the Regents of the University of California, San Francisco (UCSF) for award. This evaluation will run from July 1, 2019, to June 30, 2021, and will be completed in two phases. Phase one will include HPSM, and phase two will include RCHSD. UCSF is slated to begin contracting work on July 1, 2019.

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http://www.dhcs.ca.gov/provgovpart/Pages/Medi-Cal2020Evaluations.aspx

COMMUNITY-BASED ADULT SERVICES (CBAS)

AB 97 (Chapter 3, Statutes of 2011) eliminated Adult Day Health Care (ADHC) services from the Medi-Cal program effective July 1, 2011. A class action lawsuit, Esther Darling, et al. v. Toby Douglas, et al., sought to challenge the elimination of ADHC services. In settlement of this lawsuit, ADHC was eliminated as a payable benefit under the Medi-Cal program effective March 31, 2012, to be replaced with a new program called Community- Based Adult Services (CBAS) effective April 1, 2012. DHCS amended the “California Bridge to Reform” 1115 Demonstration Waiver (BTR waiver) to include CBAS, which was approved by CMS on March 30, 2012. CBAS was operational under the BTR waiver for the period of April 1, 2012, through August 31, 2014.

In anticipation of the end of the CBAS BTR Waiver period, DHCS and the California Department of Aging (CDA) facilitated extensive stakeholder input regarding the continuation of CBAS. DHCS proposed an amendment to the CBAS BTR waiver to continue CBAS as a managed care benefit beyond August 31, 2014. CMS approved the amendment to the CBAS BTR waiver, which extended CBAS for the duration of the BTR Waiver through October 31, 2015.

CBAS continues as a CMS-approved benefit through December 31, 2020, under California’s 1115(a) Medi-Cal 2020 waiver approved by CMS on December 30, 2015.

Program Requirements:

CBAS is an outpatient, facility-based program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, nutrition services, and transportation to eligible Medi-Cal members that meet CBAS criteria. CBAS providers are required to: 1) meet all applicable licensing and certification, Medicaid waiver program standards; 2) provide services in accordance with the participant’s multi-disciplinary team members and physician-signed Individualized Plan of Care (IPC); 3) adhere to the documentation, training, and quality assurance requirements as identified in the Medi-Cal 2020 waiver; and 4) exhibit ongoing compliance with the requirements listed above.

Initial eligibility for the CBAS benefit is determined through a face-to-face assessment by a Managed Care Plan (MCP) registered nurse with level-of-care experience, using a standardized tool and protocol approved by DHCS. An initial face-to-face assessment is not required when a MCP determines that an individual is eligible to receive CBAS and that the receipt of CBAS is clinically appropriate based on information the plan possesses. Eligibility for ongoing receipt of CBAS is determined at least every six months through the reauthorization process or up to every 12 months for individuals determined by the MCP to be clinically appropriate. Denial of services or reduction in the requested number of days for services requires a face-to-face assessment.

The State must ensure CBAS access and capacity in every county where ADHC

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services were provided prior to CBAS starting on April 1, 20121. From April 1, 2012, through June 30, 2012, CBAS was only provided as a Medi-Cal FFS benefit. On July 1, 2012, 12 of the 13 County Organized Health Systems (COHS) began providing CBAS as a managed care benefit. The final transition of CBAS benefits to managed care took place beginning October 1, 2012. In addition, the Two-Plan Model (available in 14 counties), Geographic Managed Care plans (available in two counties), and the final COHS county (Ventura) also transitioned at that time. As of December 1, 2014, Medi-Cal FFS only provides CBAS coverage for CBAS-eligible participants who have an approved medical exemption from enrolling into managed care. The final four rural counties (Shasta, Humboldt, Butte, and Imperial) transitioned the CBAS benefit to managed care in December 2014.

Effective April 1, 2012, eligible participants can receive unbundled services (i.e. component parts of CBAS delivered outside of centers with a similar objective of supporting participants, allowing them to remain in the community) if there are insufficient CBAS Center capacity to satisfy the demand. Unbundled services include local senior centers to engage participants in social and recreational activities, group programs, home health nursing, and/or therapy visits to monitor health status and provide skilled care and In-Home Supportive Services (IHSS) (which consists of personal care and home chore services to assist participants with Activities of Daily Living or Instrumental Activities of Daily Living). If the participant is residing in a Coordinated Care Initiative (CCI) county and is enrolled in managed care, the Medi-Cal MCP will be responsible for facilitating the appropriate services on the participants’ behalf.

Enrollment and Assessment Information:

Per STC 52(a), CBAS enrollment data for both Managed Care Plans (MCPs) and Fee-for-Service (FFS) members per county for DY14-Q2, represents the period of October to December 2018. CBAS enrollment data is shown in the table, titled Preliminary CBAS Unduplicated Participant - FFS and MCP Enrollment Data with County Capacity of CBAS. The table titled CBAS Centers Licensed Capacity provides the CBAS capacity available per county, which is also incorporated into the first table.

The CBAS enrollment data as described in the table below is self-reported quarterly by the MCPs. Some MCPs report enrollment data based on the geographical areas they cover which may include multiple counties. For example, data for Marin, Napa, and Solano are combined, as these are smaller counties and they share the same population.

1 CBAS access/capacity must be provided in every county except those that did not previously have ADHC centers: Del Norte,

Siskiyou, Modoc, Trinity, Lassen, Mendocino, Tehama, Plumas, Glenn, Lake, Colusa, Sutter, Yuba, Nevada, Sierra, Placer, El Dorado, Amador, Alpine, San Joaquin, Calaveras, Tuolumne, Mariposa, Mono, Madera, Inyo, Tulare, Kings, San Benito, and San Luis Obispo.

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Preliminary CBAS Unduplicated Participant - FFS and MCP Enrollment Data with County Capacity of CBAS

DY13-Q3 DY13-Q4 DY14-Q1 DY14-Q2

Jan -Mar 2018 Apr - Jun 2018 Jul - Sep 2018 Oct - Dec 2018

County Unduplica ted

Participan ts (MCP &

FFS)

Capac ity

Used

Unduplic ated

Participa nts (MCP

& FFS)

Capac ity

Used

Unduplic ated

Participa nts

(MCP & FFS)

Capaci ty

Used

Unduplic ated

Participa nts

(MCP & FFS)

Capacity Used

Alameda 518 78% 510 77% 539 82% 532 81%

Butte 43 42% 34 33% 37 36% 34 33%

Contra Costa

223 69% 232 72% 240 73% 212 64%

Fresno 634 57% 676 61% 602 46% 658 50%

Humboldt 86 22% 100 26% 95 24% 107 28%

Imperial 338 56% 307 51% 308 51% 305 51%

Kern 79 23% 83 25% 72 21% 96 28%

Los Angeles

21,381 65% 21,983 67% 21,414 63% 21,591 64%

Merced 88 42% 94 45% 94 45% 95 45%

Monterey 109 59% 107 57% 106 57% 105 56%

Orange 2,268 54% 2,329 53% 2,369 54% 2,440 55%

Riverside 449 41% 450 42% 470 43% 465 43%

Sacrament o

437 70% 440 70% 367 59% 332 40%

San Bernardino

640 86% 650 87% 677 91% 694 93%

San Diego 2,068 56% 2,138 57% 2,238 60% 2,079 56%

San Francisco

693 44% 672 43% 684 44% 705 45%

San Mateo 56 27% 65 28% 65 28% 63 28%

Santa Barbara

* * * * * * * *

Santa Clara 617 45% 224 16% 611 43% 606 42%

Santa Cruz 103 68% 110 72% 108 71% 107 70%

Shasta * * * * * * * *

Ventura 892 62% 905 63% 898 62% 909 63%

**Yolo 290 76% 282 74% 287 76% 290 76%

Marin, Napa, Solano

80 16% 80 16% 83 17% 79 16%

Total 32,104 62% 32,489 61% 32,364 59% 32,504 59%

FFS and MCP Enrollment Data 12/2018

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*Pursuant to the Privacy Rule and the Security Rule contained in the Health Insurance Portability and Accountability Act, and its regulations 45 CFR Parts 160 and 164, and the 42 CFR Part 2, these numbers are suppressed to protect the privacy and security of participants.

The data provided in the previous table shows that while enrollment has slightly increased between DY14-Q1 and DY14-Q2, it has remained consistent with over 32,000 CBAS participants. Additionally, the data reflects ample capacity for participant enrollment into most CBAS Centers with the exception of the centers located in San Bernardino County. San Bernardino County is currently operating close to its center capacity due to a steady increase in participant enrollment. However, a majority of CBAS participants are able to choose an alternate CBAS Center in nearby counties should the need arise for ongoing CBAS services.

While the closing of a CBAS Center in a county can contribute to increased utilization of the license capacity in a county, it is important to note the amount of participation can also play a significant role in the overall amount of licensed capacity used throughout the State. In Kern County, there was a more than 5% increase in licensed capacity utilized compared to the previous quarter. This increase of more than 5% capacity utilization for Kern County is likely due to a fluctuation in attendance as there were no center closures during the DY14-Q2 reporting period. No other counties reported significant increases in licensing capacity utilization between the two previous quarters. In Contra Costa and Sacramento Counties, there was more than a 5% decrease of license capacity utilization compared to the previous quarter. CDA approved an increase in overall licensing capacity for Sacramento County, which explains the decrease in capacity utilization. The decrease in license capacity utilization in Contra Costa County is likely due to general attendance fluctuation, as there were no center openings in or near Contra Costa County during the DY14-Q2 reporting period.

CBAS Assessments for MCPs and FFS Participants

Individuals who request CBAS services will be given an initial face-to-face assessment

by a registered nurse with qualifying experience to determine eligibility. An individual is

not required to participate in a face-to-face assessment if an MCP determines the

eligibility criteria is met based on medical information and/or history the plan possesses.

The following table, titled CBAS Assessments Data for MCPs and FFS reflects the

number of new assessments reported by the MCPs. The FFS data for new

assessments listed in this table is reported by DHCS.

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CBAS Assessments Data for MCPs and FFS

Demonstration Year

MCPs FFS

New Assessments

Eligible Not

Eligible New

Assessments Eligible

Not Eligible

DY13-Q3 (1/1-3/31/2018)

2,213 2,188

(98.9%) 25

(1.1%) 8

7 (87.5%)

1 (12.5%)

DY13-Q4 (4/1-6/30/2018)

2,446 2,386

(97.5%) 60

(2.5%) 5

5 (100%)

0 (0%)

DY14-Q1 (7/1-9/30/2018)

2,369 2305

(97.3%) 64

(2.7%) 4

4 (100%)

0 (0%)

DY14-Q2 2,208 48 6 0

(10/1- 2,256 6 12/31/2018)

(97.9%) (2.1%) (100%) (0%)

5% Negative change

No No No No between last

Quarter

Requests for CBAS services are collected and assessed by the MCPs and DHCS. As indicated in the table above, the number of CBAS FFS participants has maintained its decline due to the transition of CBAS into managed care. According to the table, for DY14-Q2, there were (2,256) assessments completed by the MCPs, of which (2,208) were determined to be eligible and (48) were determined to be ineligible. The table identifies that 6 participants were assessed for CBAS benefits under FFS, and all were determined eligible by DHCS.

CBAS Provider-Reported Data (per CDA) (STC 52.b)

The opening or closing of a CBAS Center affects the CBAS enrollment and CBAS Center licensed capacity. The closing of a CBAS Center decreases the licensed capacity and enrollment while conversely new CBAS Center openings increase capacity and enrollment. The California Department of Public Health licenses CBAS Centers and CDA certifies the centers to provide CBAS benefits and facilitates monitoring and oversight of the centers.

The next table titled CDA-CBAS Provider Self-Reported Data identifies the number of counties with CBAS Centers, total license capacity, and the average daily attendance (ADA) for DY14-Q2. The ADA at the 248 operating CBAS Centers is approximately 22,989 participants, which corresponds to 71% Statewide ADA per center. As the result of an increase in the total unduplicated participants in DY14-Q2, a rise in ADA was seen compared to the previous quarter. Additionally, one new CBAS Centers in Los Angeles County opened during DY14-Q2 that resulted in an overall increase in total statewide license capacity at 32,180 compared to the previous quarter.

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CDA - CBAS Provider Self-Reported Data

Counties with CBAS Centers 27

Total CA Counties 58

Number of CBAS Centers 248

Non-Profit Centers 55

For-Profit Centers 193

ADA @ 248 Centers 22,989

Total Licensed Capacity 32,180

Statewide ADA per Center 71% CDA - MSSR Data 12/2018


CDA provides ongoing outreach and CBAS program updates to CBAS providers, managed care plans and other interested stakeholders via the CBAS Updates newsletter. In the past quarter, CDA distributed two newsletters (October 17, 2018 and December 11, 2018) which included an update on the status of the revised CBAS Individual Plan of Care (IPC), a new ADHC/CBAS History & Physical Form developed by the California Association of Adult Day Services (CAADS) in collaboration with CDA, education and training opportunities such as the California Association of Adult Day Services (CAADS) 2018 Fall Conference, and the new CBAS Center Assessment Tool (CAT) on CBAS training requirements.

CDA provided a webinar training to CBAS providers, MCPs, software vendors and other stakeholders on the new IPC form and instructions on October 3, 2018. The current IPC was revised through a year-long stakeholder process in 2015-2016 to comply with federal Home and Community-Based (HCB) Person-Centered Planning Requirements as directed in the Medi-Cal 2020 Waiver. The new IPC is in the final stage of review for publishing in the Medi-Cal Provider Manual, and implementation of the new IPC is expected to be May 1, 2019. CDA will distribute an All Center Letter (ACL) and CBAS Updates newsletter to CBAS providers, MCPs, software vendors and other interested stakeholders informing them of the official IPC implementation date after it is published.

CDA convenes ongoing quarterly calls/outreach with all MCPs that contract with CBAS providers to (1) promote communication between CDA and MCPs, (2) update them on CBAS activities and data including policy directives, and (3) request feedback on any CBAS provider issues requiring CDA assistance. The last quarterly call was on December 12, 2018.


DHCS and CDA continue to work and communicate with CBAS providers and MCPs on

17

an ongoing basis to provide clarification regarding CBAS benefits, CBAS operations, and policy issues. This includes conducting quarterly calls with MCPs, distributing All Center Letters and CBAS Updates newsletter for program and policy updates, and responding to ongoing written and telephone inquiries.

DHCS did not experience any significant policy and administrative issues or challenges with the CBAS program during DY14-Q2. DHCS approved the revised CBAS IPC and revised CBAS sections of the Medi-Cal Provider Manual for publishing, targeted for February 15, 2019. Implementation of the new CBAS IPC is targeted for May 1, 2019. Moving forward, DHCS and CDA have updated the CBAS form/template revision process to include identification of all related forms/templates/publications that will require corresponding updates.

Consumer Issues:

CBAS Beneficiary/Provider Call Center Complaints (FFS/MCP) (STC 48.e.iv)

DHCS continues to respond to issues and questions from CBAS participants, CBAS providers, MCPs, members of the Press, and members of the Legislature on various aspects of the CBAS program. DHCS and CDA maintain CBAS webpages for the use of all stakeholders. Providers and members can submit their CBAS inquiries to [email protected] for assistance from DHCS and through CDA at [email protected].

Issues that generate CBAS complaints are collected from both participants and providers. Complaints are collected via telephone or emails by MCPs and CDA for research and resolution. Complaints collected by MCPs are generally related to the authorization process, cost/billing issues, and dissatisfaction with services from a current Plan Partner. Complaints gathered by CDA were mainly about the administration of plan providers and beneficiaries’ services. Complaint data received by MCPs and CDA from CBAS participants and providers are also summarized in the table, titled Data on CBAS Complaints, and the table titled, Data on CBAS Managed Care Plan Complaints.

Complaints collected by CDA and MCP vary from quarter to quarter. One quarter may have a number of complaints while another quarter may have none. CDA did not receive any complaints for DY14-Q2, as illustrated in the table, titled Data on CBAS Complaints. The table, titled Data on CBAS Managed Care Plan Complaints shows that MCPs received 2 beneficiary complaints and 13 provider complaints in DY14-Q2. Overall, provider complaints have increased during the last two quarters, as reported by the managed care plans.

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mailto:[email protected]:[email protected]

Data on CBAS Complaints

Demonstration Year and Quarter

Beneficiary Complaints

Provider Complaints

Total Complaints

DY13–Q3 (Jan 1 – Mar 31)

0 0 0

DY13–Q4 (Apr 1 – Jun 30)

0 0 0

DY14-Q1 (Jul 1 – Sep 30)

0 0 0

DY14-Q2 (Oct 1 – Dec 31)

0 0 0

CDA Data - Complaints 12/2018

Data on CBAS Managed Care Plan Complaints

Demonstration Year and

Quarter

Beneficiary Complaints

Provider Complaints

Total Complaints

DY13-Q3 (Jan 1 - Mar 31)

2 0 2

DY13-Q4 (Apr 1 - Jun 30)

2 0 2

DY14-Q1 (Jul 1 - Sep 30)

2 8 10

DY14-Q2 (Oct 1 - Dec 31)

2 13 15

Plan data - Phone Center Complaints 12/2018

CBAS Grievances/Appeals (FFS/MCP) (STC 52.e.iii)

Grievance and appeals data is provided to DHCS by the MCPs. According to the table, titled Data on CBAS Managed Care Plan Grievances, 25 grievances were filed with the MCPs for DY14-Q2; 5 grievances were related to “CBAS Providers,” 1 grievance was related to “Contractor Assessment or Reassessment”, and the remaining 19 grievances were related to “Other CBAS Grievances.” Specifically, 17 of these grievances are attributed to one specific provider under a single MCP.

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Data on CBAS Managed Care Plan Grievances


Grievances

CBAS Providers

Contractor Assessment

or Reassessment

Excessive Travel

Times to Access CBAS

Other CBAS

Grievances

Total Grievances

DY13-Q3 (Jan 1 - Mar

31) 0 0 0 33 33

DY13-Q4 (Apr 1 - Jun 30)

3 0 0 36 39

DY14-Q1 (Jul 1 - Sep 30)

1 0 0 5 6

DY14-Q2 (Oct 1 - Dec

31) 5 1 0 19 25

Plan data - Grievances 12/2018

For DY14-Q2, 3 CBAS appeals were filed with the MCPs. The table, titled Data on CBAS Managed Care Plan Appeals, shows that 1 appeal was related to “Denials or Limited Services” and the other 2 were categorized as “Other CBAS Appeals”.

Data on CBAS Managed Care Plan Appeals


Appeals

Denials or Limited

Services

Denial to See

Requested Provider

Excessive Travel

Times to Access CABS

Other CBAS

Appeals

Total Appeals

DY13 – Q3 (Jan 1 – Mar 31)

11 0 0 0 11

DY13 – Q4 (Apr 1 – Jun 30)

8 0 0 0 8

DY14 – Q1 (Jul 1 – Sep 30)

13 1 0 2 16

DY14 – Q2 (Oct 1 – Dec 31)

1 0 0 2 3

Plan data - Grievances 12/2018

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The State Fair Hearings/Appeals continue to be facilitated by the California Department of Social Services (CDSS) with the Administrative Law Judges hearing all cases filed. Fair Hearings/Appeals data is reported to DHCS by CDSS. For DY14-Q2, there were no requests for hearings related to CBAS services filed.


Pursuant to STC 54(b), MCP payments must be sufficient to enlist enough providers so that care and services are available under the MCP, to the extent that such care and services were available to the respective Medi-Cal population as of April 1, 2012. MCP payment relationships with CBAS Centers have not affected the center’s capacity to date and adequate networks remain for this population.

The extension of CBAS, under the Medi-Cal 2020 Demonstration will have no effect on budget neutrality as it is currently a pass-through, meaning that the cost of CBAS remains the same with the Waiver as it would be without the waiver. As such, the program cannot quantify savings and the extension of the program will have no effect on overall waiver budget neutrality.


The CBAS Quality Assurance and Improvement Strategy, developed through a year-long stakeholder process, was released for comment on September 19, 2016, and its implementation began October 2016. CDA continues to convene quarterly calls with the CBAS Quality Strategy Advisory Committee comprised of CBAS providers, managed care plans and representatives from CAADS to provide updates and receive guidance on program activities to accomplish the goals and objectives identified in the CBAS Quality Strategy. DHCS and CDA continue to monitor CBAS Center locations, accessibility, and capacity for monitoring access as required under Medi-Cal 2020. The table, titled CBAS Centers Licensed Capacity, indicates the number of each county’s licensed capacity since the CBAS program was approved as a Waiver benefit in April 2012. The table below also shows overall utilization of licensed capacity by CBAS participants statewide for DY14-Q2. Quality Assurance/Monitoring Activity reflects data through January to December 2018.

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County CBAS Centers Licensed Capacity

DY13-Q3

Jan-Mar 2018

DY13-Q4

Apr-Jun 2018

DY14-Q1 Jul-Sep 2018

DY14-Q2

Oct-Dec 2018

Percent Change

Between Last Two Quarters

Capacity Used

Alameda 390 390 390 390 0.0% 81%

Butte 60 60 60 60 0.0% 33%

Contra Costa 190 190 195 195 0.0% 64%

Fresno 652 652 772 772 0.0% 50%

Humboldt 229 229 229 229 0.0% 28%

Imperial 355 355 355 355 0.0% 51%

Kern 200 200 200 200 0.0% 28%

Los Angeles 19,365 19,380 19,974 19,984 0.1% 64%

Merced 124 124 124 124 0.0% 45%

Monterey 110 110 110 110 0.0% 56%

Orange 2,458 2,608 2608 2638 1.2% 55%

Riverside 640 640 640 640 0.0% 43%

Sacramento 369 369 369 489 33% 40%

San Bernardino

440 440 440 440 0.0% 93%

San Diego 2,198 2,198 2198 2198 0.0% 56%

San Francisco

926 926 926 926 0.0% 45%

San Mateo 135 135 135 135 0.0% 28%

Santa Barbara

60 60 60 60 0.0% *

Santa Clara 830 830 830 850 2.4% 42%

Santa Cruz 90 90 90 90 0.0% 70%

Shasta 85 85 85 85 0.0% *

Ventura 851 851 851 851 0.0% 63%

Yolo 224 224 224 224 0.0% 76%

Marin, Napa, Solano

295 295 295 295 0.0% 16%

Total 31,276 31,441 32,160 32,340 0.6% 59%

CDA Licensed Capacity as of 12/2018

*Pursuant to the Privacy Rule and the Security Rule contained in the Health Insurance Portability andAccountability Act, and its regulations 45 CFR Parts 160 and 164, and the 42 CFR Part 2, these numbersare suppressed to protect the privacy and security of participants.

The above table reflects the average licensed capacity used by CBAS participants at 59% statewide as of December 31, 2018. Overall, most of the CBAS Centers have not

22

operated at full capacity. This allows the CBAS Centers to enroll more managed care and FFS members should the need arise for these counties.

STC 52(e)(v) requires DHCS to provide probable cause upon a negative five percent change from quarter to quarter in CBAS provider capacity per county and an analysis that addresses such variance. There was no decrease in provider capacity of five percent or more throughout the participating counties in DY14-Q2 compared to the prior quarter, therefore no analysis is needed to addresses such variances. In the table titled CBAS Centers Licensed Capacity, Sacramento County saw an increase of 33 percent in their license capacity in DY14-Q2 compared to DY14-Q1, and resulted in an overall increase of in the total licensed capacity statewide.

Access Monitoring (STC 52.e.)

DHCS and CDA continue to monitor CBAS Center access, average utilization rate, and available capacity. According to the tables, titled Preliminary CBAS Unduplicated Participant - FFS and MCP Enrollment Data with County Capacity of CBAS, and CBAS Centers Licensed Capacity CBAS licensed capacity is adequate to serve Medi-Cal members in all counties with CBAS Centers. There were no closures of any CBAS Centers over the DY14-Q2 reporting period, therefore, closures did not negatively affect the CBAS Centers and the services they provide to beneficiaries. There are other centers in nearby counties that can assist should the need arise for ongoing care of CBAS participants.

Unbundled Services (STC 48.b.iii.)

CDA certifies and provides oversight of CBAS Centers. CDA and DHCS continue to review any possible impact on participants by CBAS Center closures. In counties that do not have a CBAS Center, the managed care plans work with the nearest available CBAS Center to provide the necessary services. This may include but not be limited to the MCP contracting with a non-network provider to ensure that continuity of care continues for the participant’s if they are required to enroll into managed care. Beneficiaries can choose to participate in other similar programs should a CBAS Center not be present in their county or within the travel distance requirement of participants traveling to and from a CBAS Center. Prior to closing, a CBAS Center is required to notify CDA of their planned closure date and to conduct discharge planning for each of the CBAS participants they provide services for. CBAS participants affected by a center closure and who are unable to attend another local CBAS Center can receive unbundled services in counties with CBAS Centers. The majority of CBAS participants in most counties are able to choose an alternate CBAS Center within their local area.

CBAS Center Utilization (Newly Opened/Closed Centers)

DHCS and CDA have continued to monitor the opening and closing of CBAS Centers since April 2012 when CBAS became operational. The table, titled CBAS Center History, shows the history of openings and closings of the centers. According to Table

23

below, for DY14-Q2 (October to December 2018), CDA currently has 248 CBAS Center providers operating in California. In DY14-Q2, no centers closed, and one center opened in Los Angeles County. The table below shows there was not a negative change of more than 5% from the prior quarter so no analysis is needed to addresses such variances.

CBAS Center History

Month Operating Centers

Closures Openings Net Gain/Loss

Total Centers

December 2018

248 0 0 0 248

November 2018

248 0 0 0 248

October 2018

247 0 1 1 248

September 2018

245 0 2 2 247

August 2018

244 0 1 1 245

July 2018 243 0 1 1 244

June 2018 243 0 0 0 243

May 2018 242 0 1 1 243

April 2018 242 0 0 0 242

March 2018 242 0 0 0 242

February 2018

241 0 1 1 242

January 2018

241 0 0 0 241

Evaluation:

Not applicable.

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DENTAL TRANSFORMATION INITIATIVE (DTI)

Given the importance of oral health to the overall physical well-being of an individual, California views improvements in dental care as a critical component to achieving overall better health outcomes for Medi-Cal beneficiaries, particularly children.

Through the DTI, DHCS aims to:

Improve the beneficiary's experience so individuals can consistently and easily access high quality dental services supportive of achieving and maintaining good oral health;

Implement effective, efficient, and sustainable health care delivery systems; Maintain effective, open communication and engagement with our stakeholders;

and

Hold ourselves and our providers, plans, and partners accountable for performance and health outcomes.

The DTI covers four areas, otherwise referred to as domains:

Domain 1 – Increase Preventive Services for Children

This domain was designed to increase the statewide proportion of children under the age of 20 enrolled in Medi-Cal for 90 continuous days or more who receive preventive dental services. Specifically, the goal is to increase the statewide proportion of children ages 1 to 20 who receive a preventive dental service by at least ten percentage points over a five-year period.

Domain 2 – Caries Risk Assessment (CRA) and Disease Management

Domain 2 is available in eleven (11) pilot counties and is intended to formally address and manage caries risk. There is an emphasis on preventive services for children ages 6 and under through the use of CRA, motivational interviewing, nutritional counseling, and interim caries arresting medicament application as necessary. In order to bill for the additional covered services in this domain, a provider must take a training, provide confirmation of completed CRA training as well as submit a provider opt-in attestation form. If the pilot is successful, then this program may be expanded to other counties, contingent on available DTI funding.

The following 11 pilot counties were selected as pilot counties and are currently participating in this domain: Glenn, Humboldt, Inyo, Kings, Lassen, Mendocino, Plumas, Sacramento, Sierra, Tulare, and Yuba.

Domain 3 – Continuity of Care

This domain aims to improve continuity of care for Medi-Cal children ages 20 and under by establishing and incentivizing an ongoing relationship between a beneficiary and

25

dental provider in seventeen (17) select pilot counties. Incentive payments will be made to dental service office locations that have maintained continuity of care through providing qualifying examinations to beneficiaries ages 20 and under for two, three, four, five, and six continuous year periods. If the pilots are successful, this domain may be expanded to other counties, contingent on available DTI funding.

The following 17 pilot counties were selected as pilot counties and are currently participating in this domain: Alameda, Del Norte, El Dorado, Fresno, Kern, Madera, Marin, Modoc, Nevada, Placer, Riverside, San Luis Obispo, Santa Cruz, Shasta, Sonoma, Stanislaus, and Yolo.

Domain 4 – Local Dental Pilot Projects (LDPPs)

The LDPPs support the aforementioned domains through up to 15 innovative pilot programs to test alternative methods to increase preventive services, reduce early childhood caries, and establish and maintain continuity of care. DHCS solicited proposals to review, approve, and make payments to LDPPs in accordance with the requirements stipulated. The LDPPs are required to have broad-based provider and community support and collaboration, including Tribes and Indian health programs.

The approved lead entities for the LDPPs are as follows: Alameda County; California Rural Indian Health Board, Inc.; California State University, Los Angeles; First 5 Kern; First 5 San Joaquin; First 5 Riverside; Fresno County; Humboldt County; Northern Valley Sierra Consortium; Orange County; Sacramento County; San Luis Obispo County; San Francisco City and County Department of Public Health; Sonoma County; and University of California, Los Angeles.

DTI Program Year Corresponding DYs

1 (January 1 – December 31, 2016) 11 (January 1 - June 30, 2016) and 12 (July 1, 2016 - June 30, 2017)

2 (January 1 – December 31, 2017) 12 (July 1, 2016 - June 30, 2017) and

13 (July 1, 2017 - June 30, 2018)


14 (July 1, 2018 - June 30, 2019)


15 (July 1, 2019 - June 30, 2020)


16 (July 1, 2020 - Dec 31, 2020)

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Statewide Beneficiaries Ages 1-20 with Three Months Continuous Enrollment and Preventive Dental Service Utilization [1]

September 2018

October 2018 November 2018 December

2018

Measure Period

10/2017-09/2018 11/2017-10/2018 12/2017-11/2018 01/2017-12/2018

Denominator[2] 5,532,860 5,563,744 5,549,171 5,537,891

Numerator[3] 2,532,860 2,530,503 2,518,110 N/A[4]

Preventive Dental

45.5% 45.5% 45.4% N/A[4]

[1] Data Source - Dental Dashboard DM3 September 2018 MIS/DSS Data. Utilization does not include one-year full run-out allowed for claim submission.

[2] Denominator: Three months continuous enrollment - Number of beneficiaries ages one through 20 enrolled in the Medi-Cal Program for at least three continuous months in the same dental plan during the measure year.

[3] Numerator: Three months continuously enrolled beneficiaries who received any preventive dental service (D1000-D1999 with or without an SNC dental encounter with ICD 10 codes: K023 K0251 K0261 K036 K0500 K0501 K051 K0510 K0511 Z012 Z0120 Z0121 Z293 Z299 Z98810) in the identified year.

[4] Performance for the third month of each quarter is not available due to claim submission time lag.

State Fiscal Year 2018-2019 Statewide Active Service Offices, Rendering Providers and Safety Net Clinics [1]

Delivery System

Provider Type

Quarter 1 Quarter 2

July 2018 August 2018

September 2018

October 2018

November 2018

December 2018

FFS Service Offices

5,780 5,781 5,800 5,777 5,793 5,815

Rendering 10,270 10,347 10,439 10,518 10,400 10,479

GMC[2] Service Offices

118 113 118 155 158 *

Rendering 268 376 394 397 399 *

PHP[2] Service Offices

874 933 885 1,090 1,043 *

Rendering 1,930 1,955 1,997 2,095 2,112 *

Safety Net Clinics 565 564 562 561 556 N/A[3]

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[1] Active service offices and rendering providers are sourced from FFS Dental reports PS-O-008A, PS-O-

008B and DMC Plan deliverables. This table does not indicate whether a provider provided services

during the reporting month. The count of Safety Net Clinics is based on encounter data from the DHCS

data warehouse as of October 2018. Only Safety Net Clinics who submitted at least one dental

encounter within a year were included.

[2] Active GMC and PHP service offices and rendering providers are unduplicated among the DMC plans:

Access, Health Net, and Liberty. DHCS updated the address deduplication methodology, therefore,

numbers of GMC and PHP service offices are lower than previous reports.

[3] Count of SNCs for the third month of each quarter is not available due to claim submission time lag.

Figures represented by a (*) will be updated when the date is received by DHCS.


DTI Small Workgroup

This workgroup now meets on a bi-monthly basis, the third Wednesday of the month. This workgroup met on November 15, 2018 during this quarter. The objective of these meetings is to review monthly updates regarding all DTI domains with provider representatives, dental plans, county representatives, consumer advocates, legislative staff, and other interested parties. In addition to the DTI small stakeholder workgroup, DHCS has continued its efforts to target specific groups with the assistance of stakeholders.

Domain 2 Subgroup

The purpose of this subgroup is to report on the domain’s current activities and discuss ways to increase participation from providers who are eligible to participate in the domain.

The subgroup met on December 18, 2018 during this quarter. The possibility of expanding Domain 2 to additional counties was discussed, including criteria used to select prospective counties. In order to address inherent issues with the original pilot county selection, the subgroup emphasized expansion counties should be counties with higher provider and beneficiary counts that could increase participation and then produce sufficient data to evaluate. However, no final expansion decisions were made at this meeting. The next meeting is scheduled February 19, 2019.

DTI Clinic Workgroup

This sub-workgroup is still active; however, it did not convene this quarter.

Domain 3 Subgroup

This subgroup is still active; however, it did not convene this quarter and will reconvene in the next quarter. The purpose of this subgroup is to report on the domain’s current activity and discuss ways to increase participation from providers who are eligible to participate in the domain.

28

DTI Data Subgroup

In July 2018, DHCS established a DTI data subgroup to garner stakeholder feedback on the usefulness of data reported in the DTI PY 1 Annual Report. The subgroup did not convene this quarter. This subgroup will reconvene in the next quarter for discussion of data reported in the DTI PY 2 Annual Report.

Domain 4 Subgroup

This subgroup is still active. DHCS holds bi-monthly calls with the LDPPs to receive status updates and address any outstanding questions. During this reporting period, two LDPP conference calls were held – October 24, 2018 and December 19, 2018.

DTI Webpage

The DTI webpage was updated as information became available during DY14-Q2 and will continue to be updated regularly. This quarter’s update included the DTI Domain 2 and 3 county expansion announcement, posted on December 31, 2018.

DTI Inbox and Listserv

DHCS regularly monitored its DTI inbox and listserv during DY14-Q2. The inbox is useful for interested stakeholders, such as advocates, consumers, counties, legislative staff, providers, and state associations, to direct comments, questions, or suggestions about the DTI to DHCS directly. The listserv provides another opportunity, for those that sign up, to receive relevant and current DTI updates.

In this quarter, there were 97 inquiries in the DTI inbox. Most inquiries during this reporting period included, but were not limited to the following categories: encounter data submission, payment status and calculations, resource documents, dispute inquiries for Domain 1 PY 1 and 2, and Domain 2 billing and opt-in questions. All requests were researched and responded to within seven business days.

Number of DTI Inbox Inquiries by Domain

Domain Inquiries

1 76

2 14

3 7

Total 97

The DTI email address is [email protected].

The DTI Listserv registration can be found here: http://apps.dhcs.ca.gov/listsubscribe/default.aspx?list=DTIStakeholdes

29

mailto:[email protected]://apps.dhcs.ca.gov/listsubscribe/default.aspx?list=DTIStakeholdes

A separate inbox is used for the LDPPs that participate in Domain 4. In this quarter, there were 46 inquiries in the Domain 4 inbox. Inquiries included status requests, budget changes, additional funding requests, and reimbursement questions.

The Domain 4 inbox is [email protected].

Outreach Plans

The Administrative Services Organization (ASO) shares DTI information with providers during outreach events, specifically about domains 1-3. DHCS presented information on the DTI at several venues during this reporting period. Below is a list of venues at which information on DTI was disseminated:

October 5-6, 2018: UCLA Oral Health Innovation Forum October 18, 2018: LA Stakeholder Meeting (agenda) November 6, 2018: Oral Health Subcommittee December 6, 2018: Medi-Cal Dental Advisory Committee (agenda) December 13, 2018: LA Stakeholder Meeting (agenda) December 21, 2018: San Francisco DTI Access Collaborative Expert Meeting


Domain 1

The next Domain 1 payment is scheduled January 2019.

Domain 2

FFS providers are paid weekly and SNC and DMC providers are paid on a monthly basis. The table below represents incentive claims paid for FFS, SNC, and DMC providers during the DY14-Q2 reporting period. During this time, the total incentive claims paid was $844,218.40, and 21 providers opted into the domain.

County FFS DMC SNC

Sacramento $139,321.75 $202,351 -

Tulare $487,677.65 - -

Kings $1,386 - -

Glenn $630 - -

Mendocino - - -

Inyo - - $12,852

Total Incentive Claims Paid - $844,218.40

30

mailto:[email protected]://www.dhcs.ca.gov/services/Documents/MDSD/LA%20Dental%20Stakeholders%20Meeting/Los_Angeles_Stakeholders_Meeting_Agenda_10.18.18.pdfhttp://www.first5sacramento.net/Meetings/Documents/MCDAC/18/Aug_Agd_Packet.pdfhttps://www.dhcs.ca.gov/services/Documents/MDSD/LA%20Dental%20Stakeholders%20Meeting/Los_Angeles_Stakeholder_Agenda_12.13.18.pdfhttp:844,218.40

The next table represents incentive claims paid for FFS, SNC, and DMC providers from the beginning of the Domain 2 program (February 2017) until the end of DY14-Q2 (December 2018). The total incentive claims paid for this period was $5,284,706.24, and 210 providers have opted into the domain.

County FFS DMC SNC

Sacramento $683,866 $1,902,589 -

Tulare $2,534,379.34 - -

Kings $11,938.50 - -

Mendocino - - $318,391

Inyo - - $7,434

Glenn $5,001 - -

Total Incentive Claims Paid - $4,653,598.84

Domain 2 Outreach Efforts

DHCS has continued to actively engage dental stakeholders in discussions around

outreach strategies to increase Domain 2 provider participation which includes follow-up

with recently visited providers. The ASO has emphasized outreach in underutilized

counties, based on the ratio of beneficiaries to providers. DHCS and the ASO will issue

provider notifications and work with local dental societies to initiate outreach activities

next quarter in the counties added for this domain.

Domain 2 Expansion

On December 31, 2018, DHCS announced via an electronic stakeholder blast,

expanding Domain 2 into 18 new pilot counties, bringing the pilot total to 29 counties.

The 18 additional counties, effective January 1, 2019, include:

Merced Monterey Kern Contra Costa Santa Clara Los Angeles Stanislaus Sonoma Imperial Madera San Joaquin Fresno Orange San Bernardino Riverside Ventura Santa Barbara San Diego

Selection for these additional counties will incorporate both the requirements stated in

the STCs as well as lessons learned from the operation of the pilot thus far. The main

selection criteria for the new pilot counties include, but are not limited to:

A high restorative to preventive services ratio A large provider populations

31

http:5,284,706.24

A large beneficiary populations

Domain 3

Domain 3 Outreach Efforts

In this quarter, the ASO’s outreach team visited four of the 17 pilot counties (Alameda, Madera, Riverside, and San Luis Obispo). Separately, upon review of claims activity

data, DHCS identified 27 SNCs opted into Domain 3 from which DHCS has not received

any Domain 3 claims. On October 2, 2018, DHCS emailed those SNCs with Domain 3

program information and claim submission guidelines along with the deadline for these

clinics to opt-in. Of these 27, two SNCs responded to DHCS and verified their

participation status, increasing the number of participating SNCs to 68.

Domain 3 Expansion

On December 31, 2018, DHCS announced via an electronic stakeholder blast,

expanding Domain 3 into 19 new pilot counties, bringing the pilot to 36 total counties.

The 19 additional counties, effective January 1, 2019, include:

Butte San Bernardino Solano Contra Costa San Diego Sutter Imperial San Francisco Tehama Merced San Joaquin Tulare Monterey San Mateo Ventura Napa Santa Barbara Orange Santa Clara

Additionally, DHCS will increase the Domain 3 annual incentive payment amounts by $60 per beneficiary with dates of service of January 1, 2019 or later. The new payment scale will be implemented beginning in program year 4 and for the June 2020 and June 2021 payments:

Incentive Payment Amounts for Domain 3

Continuous Years of

Incentive Payment by Beneficiary

Beneficiary Return

Current Payment

New Payment

2 $40 $100

3 $50 $110

4 $60 $120

32

Continuous Years of

Incentive Payment by Beneficiary

Beneficiary Return

Current Payment

New Payment

5 $70 $130

6 $80 $140

Domain 4

The LDPPs have utilized the email inbox, [email protected], to submit invoices electronically. Invoices are still submitted on a quarterly basis and may require additional follow up regarding backup documentation from the LDPP. DHCS has received 17 invoices from the LDPPs in this quarter. Ten invoices have been paid during DY14-Q2 for a total of $2,761,598.52, inclusive of invoices submitted during the previous quarter. Seven invoices are awaiting payment totaling $2,238,558.98, and five invoices totaling $3,142,474.84 are under review with DHCS. Once approved by DHCS, invoices are paid within a 3-4 week period. DHCS is expecting additional invoices from the LDPPs who have not complied with timely submission.

The LDPPs continued to submit budget revisions during this reporting period to roll over unused funds from PY 2017 to PY 2018. All budget revisions were reviewed and approved. Additionally, LDPPs submitted requests for additional funding based on dollars available from and originally allocated to the two LDPPs that are no longer participating in Domain 4. DHCS received nine requests for additional funds and DHCS provided all nine initial approvals. Once approval was received, the LDPPs were required to submit a revised narrative and budget. Eight of the LDPPs have submitted these deliverables to support their additional funding request(s), which are currently under review.

Consumer Issues:

Nothing to report at this time.


See the Operational/Policy Developments/Issues section for information on payments under the respective domains, as applicable.


The Dental Fiscal Intermediary, DXC, performs electronic analysis of claims submitted, which compares provider baseline data to ensure participating providers are paid accurately. Incentive payments undergo a reconciliation process with each check write of each PY. With each check write, a total incentive payment amount for the PY to date is calculated for each provider. If the provider receives an interim incentive payment, the

33

mailto:[email protected]:3,142,474.84http:2,238,558.98http:2,761,598.52

interim payment amount(s) are subtracted from what is calculated for the final check write.

Evaluation:

DHCS received CMS approval of the DTI Evaluation Design on September 12, 2017. The final DTI Evaluation Design and the CMS Approval Letter have been posted on the DTI webpage. DHCS executed the contract with its DTI Evaluator, Mathematica Policy Research, Inc. (Mathematica) on August 23, 2018.

DHCS met in-person with Mathematica’s lead evaluators on November 13, 2018. The purpose of this meeting was to discuss expectations for the evaluation, submission timelines, data questions, and other topics concerning the DTI Evaluation. As of the submission of this report, Mathematica has begun work on tasks associated with the evaluation as well as participate in future DHCS-led DTI stakeholder engagements.

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http://www.dhcs.ca.gov/provgovpart/Documents/DTIFinalEvalDesign.pdfhttp://www.dhcs.ca.gov/provgovpart/Documents/DTIEvalDesignCMSApprovalLetter.pdf

DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM

The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides an evidence-based benefit design covering the full continuum of care, requires providers to meet industry standards of care, has a strategy to coordinate and integrate across systems of care, creates utilization controls to improve care and efficient use of resources, reporting specific quality measures, ensuring there are the necessary program integrity safeguards and a benefit management strategy. The DMC-ODS allows counties to selectively contract with providers in a managed care environment to deliver a full array of services consistent with the American Society of Addiction Medicine (ASAM) Treatment Criteria, including recovery supports and services. As part of their participation in the DMC-ODS, CMS requires all residential providers to meet the ASAM requirements and obtain a DHCS issued ASAM designation. The DMC-ODS includes residential treatment service for all DMC beneficiaries in facilities with no bed limit.

The state DMC-ODS implementation is occurring in five phases: (1) Bay Area, (2) Kern and Southern California, (3) Central California, (4) Northern California, and (5) Tribal Partners. As of September 1, 2017, DHCS received a total of 40 implementation plans from the following counties: San Francisco, San Mateo, Riverside, Santa Cruz, Santa Clara, Marin, Los Angeles, Napa, Contra Costa, Monterey, Ventura, San Luis Obispo, Alameda, Sonoma, Kern, Orange, Yolo, Imperial, San Bernardino, Santa Barbara, San Benito, Placer, Fresno, San Diego, Merced, Sacramento, Nevada, Stanislaus, San Joaquin, El Dorado, Tulare, Kings, and Partnership Health Plan of California. As of January 18, 2018, DHCS has approved all counties’ implementation plans. With the 40 submitted implementation plans, 97.54% of California’s population will be covered under the DMC-ODS. Twenty-two counties are currently providing DMC-ODS services.


Prior quarters have been updated based on new claims data. For DY14-Q1 and DY14-Q2, only partial data is available at this time since counties have up to six months to submit claims after the month of service.

Beneficiaries with FFP Funding

Quarter ACA Non-ACA Total

DY13-Q3 15,537 8,351 23,600

DY13-Q4 16,726 8,787 25,207

DY14-Q1 20,070 9,883 29,615

DY14-Q2 11,163 5,176 16,195

Member Months:

Under the DMC-ODS, enrollees reported are the number of unique clients receiving services. “Current Enrollees (to date)” represents the total number of unique clients for

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the quarter. Prior quarters’ statistics have been updated, and for DY14-Q1 and DY14-Q2, there is only partial data available at this time since counties have up to six months to submit claims after the month of service.

Population Month 1 Month 2 Month 3 Quarter Current Enrollees

(to date)

ACA

11,585 11,217 11,639 DY13-Q3 15,537

12,455 12,065 11,621 DY13-Q4 16,726

14,798 13,690 11,650 DY14-Q1 20,070

8,581 7,992 5,124 DY14-Q2 11,163

Non-ACA

6,964 6,842 6,888 DY13-Q3 8,351

7,217 7,011 6,811 DY13-Q4 8,787

8,066 7,749 6,372 DY14-Q1 9,883

4,300 3,933 2,734 DY14-Q2 5,176


Monthly Technical Assistance (TA) Calls with Counties’ Leads Monthly Harbage Consulting Meetings regarding DMC-ODS Waiver California Association of Alcohol and Drug Programs Executives, Inc. (CAADPE)

Bi-Monthly Calls

SUD Waiver States Bi-Monthly Conference Calls California Health Care Foundation (CHCF) Bi-Monthly Calls Indian Health Program Organized Delivery System (IHP-ODS) Bi-Monthly Calls October 2, 2018: CMS Innovative Accelerator Program (IAP) Conference Call October 5, 2018: Colorado SUD Waiver Conference Call October 16, 2018: DHCS Opioid Workgroup Meeting October 19, 2018: Health Management Webinar Synergizing Master Plan with

County Opioid Use Disorder Work

October 19, 2018: Association of State and Territorial Health Officials (ASTHO) Fourth virtual convening of the Cross-Agency Leaders Roundtable on SUD

Prevention and Treatment

October 19, 2018: CHCF MAT Advisory Group: Treatment Starts Here October 24-25, 2018: UCLA Integrated Care Conference: Integrating Substance

Use, Mental Health, and Primary Care Services: Disruptive Innovations and

Sustaining Change

October 31, 2018: External Quality Review Organization (EQRO) Annual Report Presentation

November 5, 2018: California Correctional Health Care Services (CCHCS) and California Department of Corrections and Rehabilitation (CDCR) SUD External

Stakeholder Summit

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November 7, 2018: California Department of Public Health (CDPH) Maternal/Neonatal Task Force Meeting

November 8, 2018: CAADPE and Coalition of Alcohol & Drug Associations Quarterly Meeting

November 9, 2018: Substance Abuse and Mental Health Services Administration Conference Call: CA Substance Abuse Treatment field

November 19, 2018: California Consortium for Urban Indian Health Conference Call: IHP-ODS

November 27, 2018: CCHS and CDCR Substance Use Disorder External Stakeholder Summit

November 28, 2018: Judicial Council of California: Collaborative Justice Courts Advisory Committee Meetings

November 28, 2018: Waiver Evaluation Meeting with Harbage Consulting December 3, 2018: Pacific Southwest Addiction Technology Transfer Center

Year 2 Virtual Regional Advisory Board Meeting

December 13, 2018: Managed Care Advisory Group Quarterly Meeting and Webinar

December 18, 2018: DHCS Opioid Workgroup Meeting

DHCS staff conducted documentation trainings for two DMC-ODS counties and contract

providers. The trainings included technical assistance for county management as well

as general trainings for providers and county staff. The focus of these trainings was to

address documentation requirements for all DMC-ODS treatment services and

commonly identified deficiencies. The training occurred in the following counties:

County County/Provider Staff

Training Dates

County/Provider Staff Training

Attendees

Orange County October 17-18, 2018 15

Contra Costa County December 5-6, 2018 10


During this reporting period, CMS continued to assist DHCS with program and fiscal questions on Attachment BB for the IHP-ODS.

Consumer Issues:

Grievance and appeal data are as follows:

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Grievance Access to Care

Quality of Care

Program Requirements

Service Denials

Failure to Respect

Enrollee's Rights

Interpersonal Relationship

Issues Other Totals

Alameda - - 1 - - - - 1

Contra Costa - 1 - - - - - 1

Imperial - - - - - - - 0

Los Angeles 15 3 61 8 - 5 8 100

Marin - - - - - 1 2 3

Monterey - - - - - - - 0

Napa - - - - - - - 0

Nevada - - - - - - - 0

Orange 1 - - - - - - 1

Placer - - - - - - - 0

Riverside - 2 - - - - - 2

San Bernardino

- - - - - - 6 6

San Diego - 20 - - 2 - 2 24

San Francisco - - 1 - - - 2 3

San Joaquin - - - - - - 2 2

San Luis Obispo

- 1 - - - 1 3 5

San Mateo - - - - 2 1 - 3

Santa Barbara - - - - - - - 0

Santa Clara 1 2 1 - - 2 - 6

Santa Cruz - 1 - - 1 - 1 3

Ventura - - - - - - - 0

Yolo - - - - - - - 0

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County Grievances Appeal Resolved in

Favor of Plan

Resolved in Favor of

Beneficiary

Transition of Care Requests

Approved Denied

Alameda 1 0 - - - - -

Contra Costa 3 0 - - - - -

Imperial 0 0 - - - - -

Los Angeles 45 0 - - - - -

Marin 3 0 - - - - -

Monterey 0 0 - - - - -

Napa 0 0 - - - - -

Nevada 1 0 - - - - -

Orange 1 3 2 1 - - -

Placer 0 0 - - - - -

Riverside 1 0 - - - - -

San Bernardino 6 0 - - - - -

San Diego 45 0 - - - - -

San Francisco 2 0 - - - - -

San Joaquin 2 0 - - - - -

San Luis Obispo 7 1 - 1 - - -

San Mateo 2 0 - - - - -

Santa Barbara 0 0 - - - - -

Santa Clara 5 0 - - - - -

Santa Cruz 2 7 7 - - - -

Ventura 0 0 - - 2 2 -

Yolo 1 0 - - - - -

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All counties that are actively participating in the DMC-ODS Waiver track grievance and appeal claims. An appeal is defined as a request for review of an action (e.g. adverse benefit determination) while a grievance is a report of dissatisfaction with anything other than an adverse benefit determination. Grievances are reported by type of dissatisfaction.

DHCS is currently working with Los Angeles County regarding the high number of grievances reported. More specific information will be provided in the next quarterly report.


Aggregate Expenditures: ACA and Non-ACA

Population Units of Service

Approved Amount

FFP Amount SGF Amount County Amount

DY13-Q3

ACA 1,123,304 $30,552,368.07 $26,885,432.44 $2,430,880.31 $1,236,055.32

Non-ACA 628,809 $12,259,439.64 $6,155,775.22 $2,045,663.03 $4,058,001.39

DY13-Q4

ACA 852,840 $27,421,684.47 $23,903,362.58 $2,242,059.30 $1,276,262.59

Non-ACA 508,086 $11,088,675.71 $5,615,014.84 $1,445,082.78 $4,028,578.09

DY14-Q1

ACA 1,146,452 $32,041,665.14 $27,993,675.56 $2,460,028.83 $1,587,960.75

Non-ACA 725,270 $13,734,460.62 $6,938,032.39 $1,711,133.75 $5,085,294.48

DY14-Q2

ACA 634,243 $17,252,409.34 $15,057,635.58 $1,285,510.41 $909,263.35

Non-ACA 346,800 $6,976,964.60 $3,553,950.35 $1,018,069.92 $2,404,944.33

ACA and Non-ACA Expenditures by Level of Care

For details of ACA and Non-ACA expenditures by level of care, please refer to the attached Excel file, tabs “ODS Totals ACA” and “ODS Totals Non-ACA.” Beginning in DY14-Q1, the new reporting format is being used to report expenses. A level of care is now reported on one line, rather than reported by location. For example, Case Management can be provided in Intensive Outpatient Treatment (IOT) and Outpatient (ODF) settings. Rather than report two lines for Case Management under IOT and ODF, all Case Management expenses are reported on one line.

There are now twenty-two counties participating in the DMC ODS waiver as of

December 1, 2018, with eleven new counties implementing the waiver in DY 14. Of the

eleven counties, eight started providing services in July, 2018. From DY13-Q4 to DY

14-Q1, there was an increase in total approved claims of 18%, from $38.5 million to

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$45.5 million. Over the past four quarters, claims for Methadone dosing and Residential

3.5 comprise 24% and 22%, respectively, of the $150 million in approved claims.


On-site readiness reviews are conducted to ensure counties are prepared to go live with 1115 Waiver services and provide technical assistance with policy development. On-site readiness reviews were conducted in Sacramento County on November 14-16, 2018.

Evaluation:

On June 20, 2016, CMS approved the evaluation design for the DMC-ODS component of California’s Medi-Cal 2020 Demonstration. The University of California, Los Angeles, Integrated Substance Abuse Programs (UCLA ISAP) will conduct an evaluation to measure and monitor outcomes of the DMC-ODS demonstration project.

The evaluation focuses on four areas: (1) access to care, (2) quality of care, (3) cost, and (4) the integration and coordination of SUD care, both within the SUD system and with medical and mental health services. UCLA will utilize data gathered from a number of existing state data sources as well as new data collected specifically for the evaluation.

UCLA’s approved evaluation plan is available online at: www.uclaisap.org/ca-policy/assets/documents/DMC-ODS-evaluation-plan-Approved.pdf

UCLA continues to hold monthly conference calls with updates, activities, and meetings. The evaluation design and surveys are posted on UCLA’s DMC-ODS website at: http://www.uclaisap.org/ca-policy/html/evaluation.html

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http://www.uclaisap.org/ca-policy/assets/documents/DMC-ODS-evaluation-plan-Approved.pdfhttp://www.uclaisap.org/ca-policy/assets/documents/DMC-ODS-evaluation-plan-Approved.pdfhttp://www.uclaisap.org/ca-policy/html/evaluation.html

FINANCIAL/BUDGET NEUTRALITY PROGRESS: DSHP/LIHP

Designated State Health Program (DSHP)

Program costs for each of the Designated State Health Programs (DSHP) are expenditures for uncompensated care provided to uninsured individuals with no source of third party coverage. Under the waiver, the State receives federal reimbursement for programs that would otherwise be funded solely with state funds. Expenditures are claimed in accordance with CMS-approved claiming protocols under the Medi-Cal 2020 waiver. The federal funding received for DSHP expenditures may not exceed the non-federal share of amounts expended by the state for the DTI program.

Costs associated with providing non-emergency services to non-qualified aliens cannot be claimed against the Safety Net Care Pool. To implement this limitation, 13.95 percent of total certified public expenditures (CPE) for services to uninsured individuals will be treated as expended for non-emergency care to non-qualified aliens.

Payment FFP CPE Service Period

Total Claim

(Qtr. 1 July-Sept) $18,718,589 $37,437,178 DY 13 $18,718,589

(Qtr. 2 Oct-Dec) $0 $0 $0

Total $18,718,589 $37,437,178 $18,718,589

This quarter, the Department claimed $0 in federal fund payments for DSHP eligible

services.

Low Income Health Program (LIHP)

The Low Income Health Program (LIHP) included two components distinguished by

family income level: Medicaid Coverage Expansion (MCE) and Health Care Coverage

Initiative (HCCI). MCE enrollees had family incomes at or below 133 percent of the

federal poverty level (FPL). HCCI enrollees had family incomes above 133 through 200

percent of the FPL. LIHP ended December 31, 2013, and, effective January 1, 2014,

local LIHPs no longer provided health care services to former LIHP enrollees.

Additionally, pursuant to the Affordable Care Act, LIHP enrollees transitioned to Medi-

Cal and to health care options under Covered California.

This quarter, LIHP received $0 in federal fund payments. DHCS is still collaborating with the LIHP counties to complete final reconciliation for DY 3 through DY 9.

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GLOBAL PAYMENT PROGRAM (GPP)

The Global Payment Program (GPP) will assist public health care systems (PHCS) that provide health care for the uninsured. The GPP focuses on value, rather than volume, of care provided. The purpose is to support PHCS in their key role in providing services to California’s remaining uninsured and to promote the delivery of more cost-effective and higher-value care to the uninsured. Under the GPP, participating PHCS will receive GPP payments that will be calculated using a value-based point methodology that incorporates factors that shift the overall delivery of services for the uninsured to more appropriate settings and reinforces structural changes to the care delivery system that will improve the options for treating both Medicaid and uninsured patients. Care being received in appropriate settings will be valued relatively higher than care given in inappropriate care settings for the type of illness. The GPP program year began on July 1, 2015.

The total amount available for the GPP is a combination of a portion of the state’s DSH allotment that would otherwise be allocated to the PHCS and the amount associated with the Safety Net Care Uncompensated Care Pool under the Bridge to Reform Demonstration.


Not applicable.


Nothing to report.


Nothing to report.

Consumer Issues:

Nothing to report.


Payment FFP Payment IGT Payment Service Period

Total Funds Payment

PY 3, IQ4 (April - June)

$226,102,839.50 $226,102,839.50 DY 13 $452,205,679

PY 3 (July -March) Overpayment collection

($6,386,583.50) ($6,386,583.50) DY 13 ($12,773,167)

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Payment FFP Payment IGT Payment Service Period

Total Funds Payment

PY 4, IQ1 (July -September)

$301,281,907 $301,281,907 DY 14 $602,563,814

Total $520,998,163 $520,998,163 $1,041,996,326

DY14-Q2 reporting includes GPP payments made on October 11, 2018. The payment made during this time period was for PY 3, Interim Quarter (IQ) 4 (April 1, 2018 – June 30, 2018), and PY4-Q1 (July 1, 2018 – September 30, 2018).

In PY 3, IQ4, the PHCS received $226,102,839.50 in federal fund payments and $226,102,839.50 in IGT for GPP. In PY 4, IQ 1, the PHCS received $301,281,907 in federal fund payments and $301,281,907 in IGT for GPP.

DHCS recouped $12,773,167 in total funds. The recoupment was due to overpayment to Ventura County Medical Center (VCMC). In PY 3, IQs 1-3 (July 1, 2017 – March 30, 2018), VCMC was paid 75% of its total annual budget. On August 15, 2017, VCMC submitted an interim year-end summary aggregate report. The threshold points earned for VCMC were 6,161,963, or 63.71% of GPP thresholds. The 63.71% is less than 75% of its total annual budget. DHCS adjusted the payments previously made to VCMC for GPP PY 3 and recouped the difference in the amount of $12,773,167 in total funds from VCMC.


Nothing to report.

Evaluation:

The GPP Final Evaluation Report is currently being developed by the RAND Corporation